Intelligent Healthcare Information Integration 2/6/09

Go Big by Thinking Small

I don’t know about you, but this whole economic meltdown has me worried. I’m worried for my family, for my little local hospital, for my little rural community, for my practice and the families we serve, for the future of healthcare …

OK, ‘nuff said about my anxieties. On to a solution or two.

(I hate whining. That’s for depressing, “poor me” chats over a beer or three. As the testosterone-laden male that I am, I want to know the problem, sure, but mostly I want to know how we go about fixing it. So, now, where’s my toolbox?)

Speaking of my tools, history is one of my greatest wrenches. Utilizing the lessons hard won from days gone by, I believe you avoid silly missteps and can tighten up many a loose nut which you might otherwise miss. (Please hold your “loose nuts” comments until the end.) I also believe many “advanced” minds often overlook the power of historical context and reference.

Currently, I am praying daily that the new Obama administration folks don’t neglect their history lessons as they approach the absolutely monumental challenges before them. Recent HIT efforts/failures and the Great Depression can provide clues to some serious answers for our current healthcare, environmental, and even economic woes, if we heed their warnings. With this in mind, I’d like to offer them an absolutely brilliant solution designed to:

1. Deliver the 70% of the population currently being ignored by most HIT projects;
2. Enable the NHIN goal for all Americans, utilizing a tool we already have;
3. Minimize the impact of more technology upon the already strained electrical power grid;
4. Provide jobs and lower healthcare costs;
5. Stimulate PHR participation while providing a tax break to all, and;
6. Eliminate all forms of STDs from the entire planet.

Yes, just stretching it a bit on that last one, but drop dead serious about the rest. Kidding? Nope. Not even a little. While the naysayers out there will poo-poo such grandiose proclamations, if the rest of you will willingly suspend disbelief for a moment, I will explain, very succinctly, after two short points.

First, small communities and their associated community hospitals provide care for some 70% or so of the U.S. population. They have been virtually ignored by the past 25 years of HIT development. They’ve been awaiting the trickle down from big medical center/large regional/big money projects. It has been a long, boring wait with no brass ring in sight. And now, the global economic crisis threatens them even more.

Second, the big boys and their big-money mindsets are notoriously neglectful of the little people. Their big projects often don’t provide down-scalable answers that work well for smaller markets. However, as many a grassroots phenomena illustrates (recent evidence: Obama campaign), starting with an answer from the little folks can absolutely engender big, even huge results for everyone.

Consider this:

1. Begin to build the national health information database using a system we already have. If they’re already planning to provide a tax break, build in an incentive for extra bucks for those who opt in and provide some basic demographics and maybe allergy history to a national healthcare database. Why not use the IRS? Who has more info on everyone already? (OK, CIA aside). They already have a national electronic input form; all you’d need is something similar to the check box they use for donating a dollar to the presidential campaign.
2. Develop a small community HIT mindset. Start with a system designed for the end user, a basic EHR/PHR combo that provides end user satisfaction and doesn’t try to compete with the big boys doing everything for everybody. Push this inward toward the hospital and outward toward the community at the same time allowing everyone in the community to go through the growing pains together. People are empowered by, and engaged with, their communities; use this to provide mass motivation to all of a given community’s doctors, hospitals, and individuals — all together, all at once. Patient-centered, but community-driven.
3. Use open source as much as possible. Save taxpayer dollars. (Sorry, all my HIT vendor friends).
4. Associate green technology with HIT deployment. Every new computer component in every doc’s office, home, or hospital is going to add to the already overburdened power grid, not to mention add to electric bills we all have trouble paying. Offer incentives to add a solar panel or micro wind turbine for each new system, residential or commercial. It may not lower your heating costs, but it could offset any increase in power consumption.
5. Use small business incentives to develop small community employment to deploy, train, and service these new technologies. Provide jobs for people to help us ‘technologize’ healthcare, contain our energy demand, and create the real NHIN from the grasses’ roots up.

Large problems need gigantic answers. But that doesn’t mean it has to be from or for the giants. Little guys, in little communities, eventually all working together can generate an unstoppable force.

Don’t just throw money at the big boys. Go big by thinking small.

Dr. Gregg Alexander is a grunt-in-the-trenches physician and admitted geek. He runs an innovative, high-tech, rural pediatric practice in London, OH, and can be reached at doc@madisonpediatric.com.

News 2/5/09

West Memphis, AR police call Wednesday’s car bombing of the chair of the state’s medical board a terrorist attack. A bomb was placed in or near the Lexus SUV of family practice physician Trent Pierce MD, which exploded in his driveway. He’s in critical condition.

The VA’s MyHealtheVet PHR wins the best PHR ward at TEPRs. The top "Hot Product" award went to the Private Access suite of solutions.

RelayHealth launches a new insurance payment reconciliation service for healthcare providers. RelayReconcile Payment Services converts paper EOBs into electronic remittance advice (ERA) files, and then reconciles the ERAs with bank deposits. Providers are able to automatically post payments to their patient accounting system.

A Reno federal judge rules that state laws and the federal privacy act do not prevent the questioning of a doctor of someone involved in a lawsuit. The case involves a wrongful death suit against a pharmaceutical company. The pharma lawyer calls the ruling a "dangerous precedent" that violates Nevada’s privacy rules. The ruling might end up in appeals court.

A group planning to rate doctors using their individual Medicare data is thwarted when an appeals court overturns an earlier warning that required the federal government to turn the data over.

Henry Backe, MD tells the Senate Banking Committee that his practice’s retirement fund lost $11.6 million as a result of the alleged Ponzi scheme run by Bernard Madoff.  Fifteen physicians and 125 staff members from the Orthopaedic Specialty Group (CT) will likely recover a mere $500,000 of their total investment.

iPhone now offers 745 different applications in its healthcare and fitness categories. Inga’s kind of geeky about variety of applications available, which include calorie counters, pedometers, and blood pressure trackers.  For $49.99 you can also purchase My Life Record PHR.  It looks cool, but when we decide to actually use a PHR, we’ll probably go with one of the freebies.

A Kansas doctor accused in 59 overdose deaths is found to be connected to Cephalon, makers of the Actiq fentanyl lollipop. The company was charged with over-marketing the highly addictive drug for routine conditions such as headaches and paid $425 million in settlements and fines. One of the doctor’s patients died of fentanyl intoxication; the family is suing the doctor and the drug company.

And, speaking of PHRs: User Centric releases the results of  an independent study comparing the usability of Google Health and Microsoft Health Vault. The 30 participants preferred Google Health, finding its navigation and data entry was easier and utilized more familiar medical terminology.

Humana becomes the first insurance company to support MGMA’s Project SwipeIT, a standard, rigid, machine-readable insurance card that could save up to $1 billion per year.

An osteopathic surgeon who generated 125 medical malpractice lawsuits over a seven-month period files a $50 million lawsuit against his lawyer. John A. King, DO claims his attorney is guilty of negligence, legal malpractice, and breach of contract.  King apparently has an extensive history of suing hospitals who terminated his privileges, medical boards who took away his licenses, and lawyers he hired to represent him. Wow. How did he have time to practice medicine?

Both the American Academy of Family Physicians and the American College of Physicians are encouraging lawmakers to support healthcare in any economic stimulus package. Among other projects, the organizations are recommending support for HIT initiatives.

An Allscripts survey finds that physician groups are overwhelmingly happy to take federal stimulus money to use toward EHR adoption. Less consensus was found in what form the payments should take — being paid to buy EHRs or being paid to use them. Two-third of doctors said they would participate in a pay-for-purchase program, and not surprisingly, practices that already have EHRs think Uncle Sam should reimburse them retroactively. Survey flaws: only 15% of the respondents were actual providers; the rest were administrative staff. EHR users made up 60% of those surveyed, far outpacing overall adoption. And, the response rate was less than four percent. That’s not a criticism of the survey, just the usual cautions about drawing conclusions from it.

A new Institute of Medicine study concludes that the existing HIPAA privacy rule does not protect privacy as well as it should.  Also, as currently implemented, HIPAA impedes health research.

Cielo MedSolutions announces a 300% year-on-year increase in revenues in 2008 and a 400% increase in its client base. Cielo, started in 2005, provides clinical management systems to help ambulatory care providers improve, document, and report on clinical care initiatives.

Now that Daschle is out as HHS secretary candidate, will HIMSS withdraw its formal (as opposed to informal?) letter of support?

An AHRQ report finds that patients who clearly understand after-hospital care instructions are 30% less likely to be re-admitted or visit the ER. Also, costs for hospitalization and outpatient expenses are, on average, $412 lower for patients who receive complete information.

The Texas State Attorney General charges a  now-defunct imaging center for failing to retain mammogram results and copies of patient records for the required minimum for five years (or 10 years if no additional mammograms are performed at the facility). Central Imaging Center in Brownsville sold a large number of old screening films to a silver refinery business. The imaging center’s owner is now faced with penalties of up to $25,000 for each violation. (Inga is obsessing over the possibility that her silver jewelry may have once been a breast x-ray.)

Our HIStalkPractice readership continues to climb higher every week, so thanks for reading.  Feel free to sign up for e-mail updates if you haven’t already – just put your e-mail address in the Get Instant Updates box to your upper right. We already have several sponsor commitments (thanks!) and will continue offering introductory rates through the end of February. Contact Inga to learn more.

E-mail Inga.
E-mail Mr. HIStalk.

An HIT Moment with … Garrison Bliss

An HIT Moment with ... is a quick interview with someone we find interesting. Garrison Bliss, MD, is president of the Qliance Medical Group of Washington, a medical practice that charges patients a monthly fee ranging from $49 to $129 for unrestricted access to its physicians and nurse practitioners.

Describe Qliance’s business model, how it works for patients, and how the concept fits into the debate about healthcare reform.

Qliance’s business model is a sincere attempt to address the central issues in the breakdown of healthcare — the gradual and inexorable destruction of primary care, the growth of insurance distorted medical care, and the loss of personal, unhurried medical visits. 

In primary care, insurance reimbursement systems have consistently undervalued and underpaid primary care providers. Over the last 50 years, this has translated into primary care physician practices mowing through 25-35 patients a day, much to the detriment of both the physicians and the patients. 

By using an insurance vehicle for a low-reimbursement specialty, the ratio of payment to the cost of getting paid is about 2 to 1 (meaning that 50% of primary care money is burnt up in the transaction costs, before even considering overhead costs of the medical practice itself). This has been disastrous. The combination of poor reimbursement and rapid fire low value medical has made primary care a dying profession and has put patients in danger.

When we eliminate the insurance middleman, the quality of life for both doctor and patient improve dramatically. Patients also become the source of physician income and the appropriate overseers of our work. This makes it possible for doctors to truly be accountable to their patients. Service improves, price declines, and physician/patient satisfaction makes a rapid comeback. There is also ample scientific evidence that medical care based upon a strong primary care system is less expensive, more effective, and safer than a care system dominated by specialist care.

What does the "medical home" concept mean to patients and their doctors?

The medical home means that patients know who their doctor is and their doctor knows who they are. It harkens back to better days when medical care was less technical and more personal. It also means that patients have someone they can trust helping them with difficult decisions, someone who isn’t selling them (or their insurance company) an overpriced invasive test, someone who can provide insight and perspective without a vested interest in cranking up their medical care expenses. 

In the case of Qliance, it also means that they have a place to go on weekends, mornings, and evenings that isn’t an emergency room, that has their records, and that will do what needs to be done most of the time without breaking the bank.

What is the advantage for your doctors and what technologies do you use to support them?

The biggest boon for our doctors is the opportunity to practice real medicine at a much more leisurely pace without inviting bankruptcy. 

Medicine is perhaps the most rewarding of all professions, but it can also be a dismal disappointment to go home at the end of a breakneck day knowing that you short-changed every patient you saw. We eliminate this problem. 

We have many technologies — a paperless office; a secure EMR with access from work, home, or anywhere on the Internet; a digital X-ray system with Internet-based radiology backup; an on-site generic formulary; a digital phone system; patient access to physicians via phone/cell/e-mail; a direct digital interface between our lab and EMR; a Web-based answering service designed to get you in contact with someone who can actually help you after hours, etc.

Can the concept be scaled up or replicated?

We believe it can and we intend to prove it.

What are the most important lessons learned from Qliance’s experience?

1. There is enormous power in doing the right thing, but there is no reason to believe that it will be easy.
2. It is hard to go wrong if you build something that works for both patients and physicians.
3. If you criticize entrenched interests, you can expect to be attacked by them.
4. You will be misunderstood. If you can’t handle criticism, you can’t do anything this revolutionary.
5. There is nothing more enlivening than doing the impossible. It is even more fun to do it well.

News 2/3/09

The AMA claims victory after the US Court of Appeals rules that physicians do not have to disclose personal physician payment data. The AMA also launches its redesigned Web site.

Congress take note: a Computerworld article concludes that doctors won’t accept EHRs until costs AND risks can be reduced. Agreed. Doctors don’t want their productivity to suffer. Reducing risk includes providing EHRs that are intuitive and easy to use.

Charlotte Radiology (NC) selects IMAGINEradiology PM for billing and collections. The practice employs over 70 physicians.

Columbia Doctors, The Physicians and Surgeons of Columbia University selects MxSecure as its transcription vendor of choice to integrate with its Allscripts EHR. MxSecure is implementing a custom interface to move transcribed reports into the Allscripts system. Columbia Doctors includes 1,100 medical practitioners.

FQHC Crusader Community Health (IL) chooses the eClinicalWorks EMR/PM solution for its 54 providers and four locations.

The latest post by Dr. Joel Diamond is a must-read. It’s perfect entertainment for the day after the Super Bowl. (Joel says not to feel bad if it makes you laugh).

Dr. Diamond, by the way, is the chief medical officer for dbMotion, which was just chosen by UMass Memorial Health Care (MA) to create a single, interoperable electronic patient record across various IT environments and care areas.

OmniMD’s EMR receives SureScripts certification.

Cambridge Health Alliance (MA) will close six of its facilities and reduce headcount by 8% in reaction to state budget cuts. CHA had already frozen hiring and started laying off 300 employees.

A University of Chicago study finds that 90% of hospitalized patients couldn’t correctly name even one of the doctors taking care of them. Three quarters had no idea and 60% of the rest were wrong. Unfortunately, remembering a doctor’s name isn’t necessarily a good thing. Patients able to name one of their physicians were more likely to be unsatisfied with their care.

Quality Systems, the parent company of NextGen Healthcare, reports a 17% jump in net income in its fiscal third quarter, to $13.2 million. Revenue grew 36% to $65.5 million. The bulk of the earnings came from the NextGen division, which posted $61.5 million in revenue (up 40%) and operating income of $22.8 million (up 28%). About $7.5 million of NextGen’s revenues came from two separate practice management companies acquired last year.

A Chicago-area cardiologist is charged with billing insurance companies over $13 million for services never provided. A second physician is charged with healthcare fraud in a scheme that involved submitting $500,000 in false claims to exhaust patients’ deductibles and collect payments. Must be that Chicago water.

Navigenics develops a physician portal that enables physicians to access the genomic results of consenting patients and incorporate the information into the patient’s personalized health plan.

North Medical PC (NY) lays off 50 employees across clinical and support areas. The practice includes more than 70 providers and over 500 employees.

A Washington University (MO) medical practice becomes the first in St. Louis to operate under the “direct access,” a.k.a. concierge medicine, model. Patients will pay $500 to $5,000 per year. In a letter to patients, the practice said, “We have become increasingly frustrated by a system that forces doctors to see more and more patients each day to cover an increasing overhead dictated by our association with Medicare and private insurance companies. Physicians and staff are buried under piles of paperwork, which has nothing to do with patient care and all too much to do with insurance company profits. We find this situation intolerable. Under the direct access model, we will no longer be participating in any insurance plans.”

An ER physician group at Anne Arundel Medical Center (MD) donates $1 million towards a new emergency department. Doctor’s Emergency Services, a group of 25 providers, is making the donation over the next several years.

Premera Blue Cross introduces a real-time cost estimation and claims adjudication tool to advise patients of their healthcare financial responsibilities.

Misys PLC names Sir James Crosby as an independent non-executive director and chairman designate with immediate effect. It is expected that Crosby will succeed Sir Dominic Cadbury as chairman this summer. Misys also announces its half-year numbers: revenue up 22%, profit more than tripled. The company says 55% of its revenues come from healthcare in the US.

A WV doctor and former town mayor is ordered to repay an insurance company $180,000 for blood tests and injections that patients never received. The doctor blames his billing staff and software, says he has nothing to do with billing, and that judges discriminated against him. He was nailed in 2007 for underreporting income from 2000-2002, when he also worked as a day trader.

Tom Daschle not only underpaid his taxes, he’s also had cozy relationships with the healthcare industry in the form of speaking fees. Among those paying for his speeches: America’s Health Insurance Plans, the National Association of Boards of Pharmacy, and life insurance companies. Obama still wants him to run HHS, but several newspapers think he should bow out. Not likely given that the new treasury secretary (meaning: IRS boss) had tax cheating problems of his own but was confirmed anyway. Honest politicians really are hard to find.

Odd lawsuit: a female plastic surgery patient sues her surgeon and the local TV station for running nude before-and-after surgery pictures of her on the air without her permission. The woman, an image consultant, says she’s lost 75% of her business. “I don’t blame them. Of course, they’d think I’m an exhibitionist freak.”

E-mail Inga.
E-mail Mr. HIStalk.

Joel Diamond 2/2/09

I write this on the eve of the Super Bowl. The outcome of the matchup between the Pittsburgh Steelers and Arizona Cardinals will be known to you before you’ll read this. I thought, however, that this would be the perfect time to reflect on how a physician’s work is never done.

Several years ago, I took my middle son to his first Steelers game. I finally got a weekend free and made sure that someone would be covering all my phone calls. I scored some great tickets and parked my car in town so my son and I could cross the Allegheny River on the bridge in true Pittsburgh style. We both got our faces painted in black and gold and we enjoyed our foot long hot dogs and Cokes. We settled in our seats and got ready for the kickoff. 

Just then, in the adjacent section, I saw a commotion around a fallen and cyanotic man. I looked at my young child next to me and said, “Son, I’m really sorry, but Daddy has to do some work after all." I handed him my cell phone and reluctantly entrusted him to the rabid fans around me.

It’s a strange phenomenon to do CPR on a person as fans cheer around you. Eventually, medics arrived and I was able to intubate and shock the unfortunate man as he lay on the metal bench while his wife looked on. I was drenched in vomit and sweat as the game continued on the field. To make matters worse, the man’s wife told me that her husband was a physician.

You’re probably wondering at this point about my son. Well he decided that it would be a good idea to call his mom. “Where’s your father? He left you alone in the stands with strangers?” she asked him. “Yeah, he’s hanging out with some other people,” he replied innocently. “Can you see him? What is he doing?” asked my confused wife. To her shock, he replied, “Oh yeah, I can see him now — he has his mouth on another man’s mouth.”

The ambulance finally came as the end of the quarter approached. I went back to my section and thanked the people who watched over my son. They asked me if I thought the guy was going to make it. I answered realistically that I very much doubted it. 

Silence fell over the entire section as people realized what had happened. I debated on what to say next.

“But what a way to go!” I shouted.

The crowd went wild.

My God, I thought, only in Pittsburgh.

Joel Diamond, MD is chief medical officer at dbMotion, adjunct associate professor at the Department of Biomedical Informatics at the University of Pittsburgh Medical Center, and a practicing physician at UPMC.